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. yyELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/N�G NO. ELL County Name WELL AND BORING CONSTRUCTION RECORD g 18 0 2 8 �� i� Minnesota Statutes,Chapter 103I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 4 23 10 �f,T SE��SW �� 204 " 5-i 16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool �Driven r�Auger `Ec�Rotary House Number,Street Name,City,and ZIP Code of Well Location i�pt� f" /� R � 91 DRILLWG FLUID WELL HYDROFRACTURED? ❑Yes - No `; �aater Show exact location of well/oring in section grid with"X" Sketch map of well/boring location. From ft.To ft. Showing property lines, ', ' . roads,butldtngs;'nd direction. USE rv , .� �Domestic ❑Monitoring ❑Heating/Cooling �. � � , � �- :,,_,- ;_.: -t ', .n ii.,. f-. ._,� :; ; _;___ __, __� __;__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial , _, ❑Community PWS ❑Irrigation �Remedial � --'-- --;-- ---`-- ---`-- Dewater �� 4 �Elevator ❑ ing .. W ; ; ; ; E CASING MATERIAL Drive Shae? �,]Yes �Q`=('No HOLE DIAM. � --'--- --`-- -""`-� ""-'-- T �� ❑Steel ❑Threaded ❑Welded � , , , , , 'Fe Mile , , , , I Plastic ❑ �.. ---------------�-- ---%- 1 ' CASING S � Diam/eter c Weight Specifications �t Miie� `t in.To ��j ft. Ibs./ft. in.To �Q ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. in.To— " tt. `�'(� �t��f� in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well locatio t SCREEN OPEN HOLE � Make�� From ft. To ft. SEP G 6 7.01F TYPe�C�I��I.CC� G� SIoUGauze_ Length Set between � fl.and ft. FITTINGS �j'TM OF ORONO STATIC WATE L Measured from � ft. Below ❑Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surtace) 2� ft.after � hrs.pumping �� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer t��h��r Model ❑Casing protection �12 in.above grade ' ❑At-grade [j Well House ❑Hand Pump 7 GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) ; t,,� � Material ��l��tF�rom � To n5� ft. � ❑Yds. �Bags Material�tu�1g� L�� SQ To �75 ft. �Yds. ❑Bags HARDNESS OF Matenal From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION to,�soil black ft 0 2 � _� -_ �- - ' __feet __ �-- direction --— ' s-�'�y �� Well disinfected upon completion? Yes ❑No -� "� Y ,_� - � � = CZHy �C{yi0C1 �.tl�l 2 Z� PUMP _ _ [j Not installed Date installed r1�7��Ei clsy gray ft 2Q 139 Manufacturer's name ��Y ��V b�,�� 1� ��y �p� Model Number HP 1�5 Volts � � � O Length of drop pipe � ft. Capacity g.p.m - ��Cl�y �ray .i� 1i72 ln� Type:� Submersibie ❑LS.Turbine ❑Reciprocating �Jet ❑ ABA DONED WELLS �ravellsand 1Tl�X i,j]j!] 173 ZtFt Does property have any not in use and not sealed well(s)? I�Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet i1 needed. REMARKS,ELEVATION,SOURCE OF DATA,eta � �'t(�O�S Well Drilifng Co,. i�• 1fi9I Licensee Business Name Lic.or Reg.No. . .�"'� � ��1� _/•" �' if' R r seni ive ' Certified Rep.No. Date , _ LOCAL COPY 81 H O 2� Name of Driller �� tO�.a18. ID#52603 HE01205-15(Rev.8/13)